TN 25 (08-23)
NL 00705.358 Continuing Disability Review (CDR) Cessation Notice
Social Security Administration
Supplemental Security Income
Notice of Disability Cessation
Date:
[Case Number]
Jane Doe for
John Smith
Street Address
City ST ZIP
IMPORTANT NOTICE
JOHN SMITH'S SSI WILL STOP
Earlier we told you we were reviewing John Smith's case to see if they are still disabled
under our rules. After reviewing all the information carefully, we have decided they
no longer qualify for Supplemental Security Income (SSI).
We urge you to read this entire letter. It includes important information about appeal
rights and medical assistance. It also explains how you can continue to receive payments
if you
appeal.
The Decision On John Smith's Case
The medical evidence shows that John Smith's health has improved and they no longer
meet the disability requirements in (Month/Year).
[Personalized Case Language (“PDN”)]
When Payments Will Stop
John Smith is no longer disabled under the definition of disability for children as
of (Month/Year). They will get SSI for that month and the next 2 months as long as they continue
to meet all other requirements until then. Their last SSI payment will be for (Month/Year).
See Next Page
[Case Number] Page 2 of 5
How To Appeal and Get Payments During the Appeal
If you want to appeal and to get payments during the appeal, you have to act fast.
You
have to ask us within 10 days after the date you get this letter. The 10 days start
when you get
this letter.
-
•
If you want to appeal, but do not want to ask for payments during the appeal, you
have to ask us within 60 days after the date you get this letter. The 60 days start
when you get this letter.
-
•
We will assume you got this letter 5 days after the date at the top, unless you show
us that it took longer for you to get it.
-
•
You have to ask us in writing to appeal and to get payments during the appeal. We
will give you the forms you need to fill out. You can call us and we will mail the
forms to you. Or, you can visit any Social Security Office to get the forms. We will
tell you how to call us at the end of this letter.
-
•
If you are late and you want to appeal or ask for payments during the appeal, you
should tell us why you were late. If we decide you have a good reason for being late,
you will still be able to appeal or get payments during the appeal.
-
•
We can help you fill out the forms if you ask us. We will also need you to give us
other information about John Smith's health problems.
Please read the enclosed pamphlet, “Your Right to Question the Decision to Stop Your
Benefits.” It contains more information about the appeal.
Will You Have To Pay Back the Money You Get During the Appeal?
If you get payments during the appeal and lose the appeal, we will ask you to pay
back some or all of the money. If this happens, you can ask that you not have to pay
us back. You will not have to pay us back if you cooperate with us during the appeal
and we find that you need your money for your usual living expenses. If you ask us,
we will give you more information about when you do not have to pay back the money.
How An Appeal Works
A Disability Hearing Officer will decide John Smith's SSI appeal. We will call this
person a DHO in the rest of our letter. The DHO will meet with you before making the
decision on the appeal. The meeting works like this.
See Next Page
[Case Number] Page 3 of 5
-
•
The DHO will mail you a letter at least 20 days before the meeting to tell you its
date, time and place.
-
•
You can look at John's file before the meeting.
-
•
You can tell the DHO the reasons you think John is still disabled. You should give
the DHO any information you think is missing from their file. If you need help in
getting the additional information, the DHO will help you. You can bring someone to
represent you at the meeting. And you can bring people to explain the reasons they
are disabled.
-
•
You can have the DHO order people to come to the meeting to speak about John's health
problems and bring important papers. You can question these people at the meeting.
-
•
You do not have to go to the meeting in person. If you do not want to go, you can
still give the DHO any more facts you may have. The DHO will decide the case using
these facts, and what is now in the file. But if you go to the meeting, it may help
the DHO decide the case.
If You Want Help With Your Appeal
You can have a lawyer, friend, or someone else help you. There are groups that can
help you find a lawyer or give you free legal services if you qualify. There are also
lawyers who do not charge unless you win your appeal. The local Social Security office
has a list of groups that can help you with your appeal.
If you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before they can collect it.
If John Smith's Health Gets Worse
If John Smith's health gets worse, please get in touch with us. They may be able to
get SSI again. We can help you file a new application for SSI.
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. So, if you disagree with this decision,
you should ask for an appeal within 60 days.
See Next Page
[Case Number] Page 4 of 5
Information About Medical Assistance
If John Smith is getting medical assistance from your State medical assistance agency,
even though they will not get SSI, they may still qualify for medical assistance to
help with health care bills. That's because many children may still qualify for medical
assistance if they live in households that still meet the income and resources rules
for SSI.
The State medical assistance agency may contact you for information they need to make
a decision about their medical assistance. If the agency decides that they are qualified
to remain on medical assistance, their medical assistance benefits will continue,
without a break in coverage.
If the State medical assistance agency decides that they are not qualified to continue
getting medical assistance, it must send you a separate letter and information about
how to appeal that decision. If you get a letter that tells you that their medical
assistance will stop, you should contact the State medical assistance agency right
away.
If you appeal that decision on time, they will continue to receive medical assistance
until the agency decides the appeal. If you have not heard from them in 60 days from
the date of this letter, you may want to contact your local medical assistance office
or the [State] Department of Health Services. If you call or visit that office, please
have this letter with you.
You may also get help to pay for John Smith's health care bills through the Children's
Health Insurance Program (CHIP) in your State. For more information about CHIP in
your State, call toll-free 1-877-KIDS NOW, or 1-877-543-7669.
If You Have Any Questions
-
1.
Visit www.ssa.gov for fast, simple, and secure online service.
-
2.
Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard
of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
-
3.
You may also call your local office at [FO telephone number from DOORS].
[Field Office Address
City ST ZIP]
How are we doing? Go to www.ssa.gov/feedback to tell us.
See Next Page
[Case Number] Page 5 of 5
(Signature)
Regional Commissioner
Enclosure:
SSA Pub. No. 05-10058
Cessation Notice
Fill-ins
IMPORTANT NOTICE
-
Earlier we told you we were reviewing (2) case to see if (3) still disabled under
our rules. After reviewing all the information carefully, we have decided (4) for
Supplemental Security Income (SSI).
We urge you to read this entire letter. It includes important information about appeal
rights and medical assistance. It also explains how you can continue to receive payments
if you appeal.
-
(1)
Choice 1: Recipient's name (possessive)
Choice 2: Your
-
(2)
Choice 1: Recipient's name (possessive)
Choice 2: Your
-
(3)
Choice 1: they are
Choice 2: you are
-
(4)
Choice 1: they no longer qualify
Choice 2: you no longer qualify
The Decision On (1) Case
The medical evidence shows that (2) health has improved and (3) the disability requirements
in (Month/Year).
[Personalized Case Language (“PDN”)]
-
(1)
Choice 1: Recipient's name (possessive)
Choice 2: Your
-
(2)
Choice 1: Recipient's name (possessive)
Choice 2: your
-
(3)
Choice 1: they no longer meet
Choice 2: you no longer meet
When Payments Will Stop
(1) no longer disabled under the definition of disability for children as of (Month/Year). (2) will get SSI for that month and the next 2 months as long as (3) to meet all
other requirements until then. (4) last SSI payment will be for (Month/Year).
-
(1)
Choice 1: Recipient's name is
Choice 2: You are
-
(2)
Choice 1: They
Choice 2: You
-
(3)
Choice 1: they continue
Choice 2: you continue
-
(4)
Choice 1: Their
Choice 2: Your
How To Appeal and Get Payments During the Appeal
If you want to appeal and to get
payments during the appeal, you have to act fast. You have to ask us within
10 days after the date you get this letter. The 10
days start when you get this letter.
-
•
If you want to appeal, but do not want to ask for payments during the appeal, you have to ask us within 60 days after the date you get this letter. The 60 days start when you get this letter.
-
•
We will assume you got this letter 5 days after the date at the top, unless you how
us that it took longer for you to get it.
-
•
You have to ask us in writing to appeal and to get payments during the appeal. We will give you the forms you need
to fill out. You can call us and we will mail the forms to you. Or, you can visit
any Social Security Office to get the forms. We will tell you how to call us at the
end of this letter.
-
•
If you are late and you want to appeal or ask for payments during the appeal, you
should tell us why you were late. If we decide you have a good reason for being late,
you will still be able to appeal or get payments during the appeal.
-
•
We can help you fill out the forms if you ask us. We will also need you to give us
other information about (1) health problems.
Please read the enclosed pamphlet, “Your Right to Question the Decision to Stop Your
Benefits.” It contains more information about the appeal.
-
(1)
Choice 1: Recipient's name (possessive)
Choice 2: your
Will You Have To Pay Back the Money You Get During the Appeal?
If you get payments during the appeal and lose the appeal, we will ask you to pay
back some or all of the money. If this happens, you can ask that you not have to pay
us back. You will not have to pay us back if you cooperate with us during the appeal
and we find that you need your money for your usual living expenses. If you ask us,
we will give you more information about when you do not have to pay back the money.
How An Appeal Works
A Disability Hearing Officer will decide (1) SSI appeal. We will call this person
a DHO in the rest of our letter. The DHO will meet with you before making the decision
on the appeal. The meeting works like this.
-
•
The DHO will mail you a letter at least 20 days before the meeting to tell you its
date, time and place.
-
•
You can look at (2) file before the meeting.
-
•
You can tell the DHO the reasons you think (3) still disabled. You should give the
DHO any information you think is missing from (4) file. If you need help in getting
the additional information, the DHO will help you. You can bring someone to represent
you at the meeting. And you can bring people to explain the reasons (5) disabled.
-
•
You can have the DHO order people to come to the meeting to speak about (6) health
problems and bring important papers. You can question these people at the meeting.
-
•
You do not have to go to the meeting in person. If you do not want to go, you can
still give the DHO any more facts you may have. The DHO will decide the case using
these facts, and what is now in the file. But if you go to the meeting, it may help
the DHO decide the case.
-
(1)
Choice 1: Recipient's name (possessive)
Choice 2: your
-
(2)
Choice 1: Recipient's first name (possessive)
Choice 2: your
-
(3)
Choice 1: (Recipient's first name) is
Choice 2: you are
-
(4)
Choice 1: their
Choice 2: your
-
(5)
Choice 1: they are
Choice 2: you are
-
(6)
Choice 1: Recipient's first name (possessive)
Choice 2: your
If You Want Help With Your Appeal
You can have a lawyer, friend, or someone else help you. There are groups that can
help you find a lawyer or give you free legal services if you qualify. There are also
lawyers who do not charge unless you win your appeal. The local Social Security office
has a list of groups that can help you with your appeal.
If you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before they can collect it.
If (1) Health Gets Worse
If (2) health gets worse, please get in touch with us. (3) may be able to get SSI
again. We can help you file a new application for SSI.
You have the right to file a new application at any time, but filing a new application
is not the same as appealing this decision. So, if you disagree with this decision,
you should ask for an appeal within 60 days.
-
(1)
Choice 1: Recipient's name (possessive)
Choice 2: Your
-
(2)
Choice 1: Recipient's name (possessive)
Choice 2: Your
-
(3)
Choice 1: They
Choice 2: You
Information About Medical Assistance
If (1) getting medical assistance from your State medical assistance agency, even
though (2) will not get SSI, (3) may still qualify for medical assistance to help
with health care bills. That's because many children may still qualify for medical
assistance if they live in households that still meet the income and resources rules
for SSI.
The State medical assistance agency may contact you for information they need to make
a decision about (4) medical assistance. If the agency decides that (5) qualified
to remain on medical assistance, (6) medical assistance benefits will continue, without
a break in coverage.
If the State medical assistance agency decides that (7) not qualified to continue
getting medical assistance, it must send you a separate letter and information about
how to appeal that decision. If you get a letter that tells you that (8) medical assistance
will stop, you should contact the State medical assistance agency right away.
If you appeal that decision on time, (9) will continue to receive medical assistance
until the agency decides the appeal. If you have not heard from them in 60 days from
the date of this letter, you may want to contact your local medical assistance office
or the [State] Department of Health Services. If you call or visit that office, please
have this letter with you.
You may also get help to pay for (10) health care bills through the Children's Health
Insurance Program (CHIP) in your State. For more information about CHIP in your State,
call toll-free 1-877-KIDS NOW, or 1-877-543-7669.
-
(1)
Choice 1: Recipient's name is
Choice 2: you are
-
(2)
Choice 1: they
Choice 2: you
-
(3)
Choice 1: they
Choice 2: you
-
(4)
Choice 1: their
Choice 2: your
-
(5)
Choice 1: they are
Choice 2: you are
-
(6)
Choice 1: their
Choice 2: your
-
(7)
Choice 1: they are
Choice 2: you are
-
(8)
Choice 1: their
Choice 2: your
-
(9)
Choice 1: they
Choice 2: you
-
(10)
Choice 1: their
Choice 2: your
If You Have Any Questions
-
1.
Visit www.ssa.gov for fast, simple, and secure online service.
-
2.
Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard
of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.
-
3.
You may also call your local office at [FO telephone number from DOORS].
[Field Office Address
City ST ZIP]
How are we doing? Go to www.ssa.gov/feedback to tell us.
(Signature)
Regional Commissioner
Enclosure:
SSA Pub. No. 05-10058